Application for a Tobacco Manufacturer, Wholesale and/or Retail

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Application for a
Tobacco Manufacturer, Wholesale and/or
Retail Vendors License
(Pursuant to the Tobacco Tax Act R.S.P.E.I. 1988)
Mail to:
Finance, Energy and Municipal Affairs,
Taxation and Property Records
PO Box 1150, Charlottetown, PE C1A 7M8
Freedom of Information and Protection of Privacy
Personal information on this form is collected under the authority of Section 31(c)
of the Freedom of Information and Protection of Privacy Act and Section 4(1) of
the Tobacco Tax Act. The information will be used for the purposes of tax
administration and enforcement. Questions on the collection and use of this
information can be directed to the Manager, Corporate and Tax Administration
Services, PO Box 2000, Charlottetown, PE C1A 7N8 (902) 368-5137.
Deliver to:
95 Rochford Street
Shaw Building, 1s t Floor South
Charlottetown, PE C1A 3T6
or: any Access PEI Centre
Tel: (902) 368 6577; Fax: (902) 368 6164
Website: www.taxandland.pe.ca
Email: [email protected]
Section A – General Information
Type of License/Permit Required:
G Manufacturer
G W holesaler
G Retailer
G Marking Permit
G Marking Exemption Permit
Applicant’s Legal Name:
Street/Mailing Address:
City or Town:
Province:
Phone No.:
Fax No.:
Postal Code:
Email:
Trade or Business Name (if different than above):
Mailing Address:
City or Town:
Province:
Phone No.:
Fax No.:
Postal Code:
Email:
Section B – Business Information
1. Type of Ownership:
G Proprietorship
G Partnership
G Corporation
G Other (specify)
2. List Full Name(s), Titles(s), Address(es) and Phone Number(s) of Proprietors/Partners or Principal Officers (attach
supplementary list, if required).
Name and Title
Address
Phone No.
%
Ownership
3. Location of Records:
4. Name of Person Responsible for Records:
Phone No.:
Em ail:
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5. Give a short description of your com pany’s activity relating to tobacco products:
6. A.
How many tobacco outlets do you operate?
W arehouses:
Retail Stores:
Cash & Carry:
Other (please specify):
B.
Attach a separate list with the name and address of each outlet by type.
7. Names and addresses of tobacco suppliers (attach supplementary list if required):
8.
For Marking Permit Applicants Only – List each location where tobacco products will be marked:
9.
Sales Information:
No. of
cigarettes
No. of
cigars
No. of
tobacco sticks
Other
(grams)
PEI sales last 12 months
Estimated PEI sales next 12 months
Imports last 12 months
Estimated imports next 12 months
Exports last 12 months
Estimated exports next 12 months
10.
Does your business currently have tobacco tax accounts with other jurisdictions?
Tax Account No.
11.
Jurisdiction
Tax Account No.
Jurisdiction
Does your business currently have a tax account with the Province of Prince Edward Island?
G Tobacco Tax Account Number
G Revenue Tax (PST) Account Number
Section C – Certification
The applicant named below hereby makes application for a license/permit issued under the Tobacco Tax Act and agrees to accept
the responsibilities as set out in the act and the Revenue Administration Act, collect the tax imposed and account to the Provincial
Tax Commissioner for all monies collected under the acts.
I certify, to the best of my knowledge and belief, that the above information is correct. I also understand that the information on this
form will be used for purposes of tax administration and enforcement pursuant to Section 20 of the Revenue Administration Act.
Name of Applicant
Signature
D ecem ber 2011
Title of Applicant
Date
Telephone
11PT 15-30604